Provider Demographics
NPI:1063444909
Name:WILLIAM D. LYLES, JR., M.D. AND ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:WILLIAM D. LYLES, JR., M.D. AND ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:LYLES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:615-374-0703
Mailing Address - Street 1:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37074-0483
Mailing Address - Country:US
Mailing Address - Phone:615-374-0703
Mailing Address - Fax:615-374-0019
Practice Address - Street 1:205 BROADWAY
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37074-1303
Practice Address - Country:US
Practice Address - Phone:615-374-0703
Practice Address - Fax:615-374-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16864207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3727762Medicaid
TN4097932OtherBLUECROSS BLUESHIELD
TN3727762Medicaid
TNC77051Medicare UPIN
TN=========OtherCOMMERCIAL